Overscreening by Val Jones MD

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Health screening is part of good preventive care, though over-screening can lead to increased costs, and potential patient harm. Healthcare professional societies have recently developed excellent public service announcements describing the dangers of over-testing, and new research suggests that though additional medical interventions are associated with increased patient satisfaction, they also lead (ironically) to higher mortality rates.

And so, in a system attempting to shift to a “less is more” model of healthcare, why is resistance so strong? When the USPSTF recommended against the need for annual, screening mammograms in healthy women (without a family history of breast cancer) between the ages of 40-49, the outcry was deafening. Every professional society and patient advocacy group rallied against the recommendation, and generally not much has changed in the breast cancer screening world. I myself tried to follow the USPSTF guidelines – and opted out of a screening mammogram for two full years past 40. And then I met a charming radiologist at a women’s medical conference who nearly burst into tears when I told her that I hadn’t had a mammogram. Her lobbying for me to “just make sure I was ok” was so passionate that I simply could no longer resist the urge to get screened.

I knew going into the test that there was a reasonably high chance of a false positive result which could cause me unnecessary anxiety. That being said, I was still emotionally unprepared for the radiologists’ announcement that the mammogram was “abnormal” and that a follow up ultrasound needed to be scheduled. I must admit that I did squirm until I had more information. In the end, the “abnormality” proved to be simple “dense breast tissue” and I was pleased to have at least dodged an unnecessary biopsy or lumpectomy. Did my screening do me any good? No, and some psychological harm. A net/net negative but without long term sequelae.

My next personal wrestling match with screening tests was the colonoscopy. I was seeing a gastroenterologist for some GI complaints, and we weren’t 5 minutes into our conversation before he recommended a colonoscopy. I argued that I was too young for a screening colonoscopy (I was 42 and they are recommended starting at age 50), and therefore was doubtful that anything too helpful would be found with the test. My suggestion was that a careful history and some blood testing might be the first place to start. My gastroenterologist acquiesced reluctantly.

As it turns out the blood testing was non-diagnostic and my symptoms persisted so I agreed to the colonoscopy. In this case I felt it was reasonable to do it since it was for diagnostic (not screening) purposes. I was quite certain that it would reveal nothing – or perhaps a false positive followed by anxiety, like my mammogram.

What it did show was some polyps that had a 50% chance of becoming malignant colon cancer in the next 10 years. I was shocked. If I had waited until I was 50 to start screening, I could have missed my cure window. The uneasiness about screening guidelines began to sink in. As a physician I had done my best to apply screening guidelines to myself and resist the urge to over-test, even with a healthy dose of natural curiosity. Yet I failed to resist screening, and in fact, my life was possibly saved by a test that was not supposed to be on my preventive health radar for another 8 years.

Screening tests are recommended for those who are most likely to benefit, and physicians and patients alike are encouraged to avoid unnecessary testing. But there are always a few people outside the “most likely to benefit” pool whose lives could be saved with screening, and the urge to make sure that’s not you – or your patient – is incredibly strong. I’m not sure if that’s human nature, or American culture. But a quick review of Hollywood blockbuster plots (where tens of thousands of lives are regularly sacrificed to save one princess/protagonist/hero from the aliens/monsters/zombies) testifies to our desperately irrational tendencies.

I am now biased towards over-testing, because my emotional relief at dodging a bullet is stronger than my cerebral desire to adhere to population-based recommendations. Knowing this, I will still try to avoid the temptation to over-test and over-treat my patients. But if they so much as hint that they’d like an early colonoscopy – I will cave.

Does that make me a bad doctor?

Dr. Jones blogs at www.getbetterhealth.com

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  5 comments for “Overscreening by Val Jones MD

  1. Pat
    August 7, 2014 at 11:09 am

    While riding in along the lines of battle at Spotsylvania in 1864, Union general John Sedgwick chided his troops who were cowering from scattered, long range rebel fire. “I’m ashamed of you dodging that way” he said, laughing, “they couldn’t hit an elephant at this distance.” A moment later he was shot in the face and killed.

    Apart from sewing up a cut or finding a broken bone on X-ray, all of medicine involves playing the odds.

  2. Jim Dickinson
    August 6, 2014 at 11:26 pm

    The emotional tangles here are real. Men with Prostate cancer among their relatives, women with fear of Breast Cancer etc. But too often advocates are playing on our hopes and fears, but not telling us the truth. First we have to learn the facts, then make decisions based on our values and preferences, based on the balance of likely benefits and harms. Sadly, even the greatest advocates of breast cancer screening cannot claim that it reduces mortality by more than 30%, while others have good reason to think it is much less, possibly zero, now that treatments are good. Worse, with all the new highly sensitive screening, even more abnormalities are being diagnosed and biopsied, with some being treated unnecessarily. So most “survivors” of breast cancer never had breast cancer at all (they had overdiagnosed non-cancer), maybe up to half did, and the treatment may have helped them regardless of whether they had screening, while 35% will die anyway, just after a longer disease course. I heard Fiona Godlee, editor of BMJ tell a conference that she does not have Mammograms: and she is one of the best informed women in the world. Otis Brawley, Chief Medical Officer of the American Cancer Society wrote a great book: “How we do harm” that goes into detail about these issues, and is an inspiring biography as well.

  3. Jeanne Blaha
    August 6, 2014 at 8:27 pm

    My niece and namesake died at age 45 from colon cancer. Had she ignored “the guidelines” and gotten a test before abdominal pains took her to the doctor, her first exam would not have shown Stage Four and she might be alive today.

  4. Randy
    August 6, 2014 at 1:43 pm

    “Bad doctor” is pretty harsh, but it’s hard to keep the right balance. On the one hand you have anecdotal experience which is valuable, on the other are the studies that are focused on populations, not individuals.

    In general though I have to say we have indeed been too aggressive with screenings. At some point the false positives, the morbidities of the tests themselves, the uncertainty of treatments, etc. outweigh the benefits. Add into that our litigious society encourages CYA and over-aggressive workups of findings that are likely benign. In my experience the requests for compression views and ultrasounds following mammograms has been steadily growing.

    Every patient should be treated as an individual, and if a little voice is telling you to order a test you should certainly do so, but you can’t have an experience with one patient dictate how you treat a population.

  5. William Bodenheimer
    August 6, 2014 at 1:32 pm

    All you need to do is follow the money trail. The radiologist wanted you to have the mammogram. The gastroenterologist wanted you to have the colonoscopy. I try to follow the USPTF recommendations as much as I can b/c they, at least, do not seem to be making money on screening testing. Anything that comes out of different specialty societies I almost always ignore b/c those specialties are making money on unnecessary screening testing. By the way, the USPTF some years ago recommended going back to stool hemocult for colon cancer screening. That is what I order at this point. About $10 vs $3500.

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